Autologous Blood Patch in Persistent Pneumothorax
By Dr. C. Mohan Rao, Dr. Debasis Behera, Dr.Saswat Subhankar, Dr. Suman Jagaty, Dr. Kinshuk Sarabhai, Department of Pulmonary Medicine, KIMS
Acute COVID is a spectrum of COVID illness upto four weeks. Ongoing symptomatic COVID refers to a period of 4-12 weeks. Post Covid sequelae is said to start after twelve weeks of illness. The effects of COVID on lung include pulmonary fibrosis, bullae, cyst in the lung parenchyma which needs evaluation and appropriate management on a priority basis for a recovery. Bronchopleural fistula is a major reason for persistent pneumothorax which can happen as a sequelae.
A 46-year male was admitted as a case of COVID-19 positive illness in KIMS COVID Hospital for around 6 weeks. On clinical evaluation of dyspnoea, it was revealed as a case of severe right sided pneumothorax. The patient was put on an intercostal tube (ICT) in right pleural space on 1st June 2021. After subsequent RT-PCR negative reports, the patient was transferred to non COVID HDU with ICT in situ.
In HDU, he was observed daily and diagnosed as a case of a persistent pneumothorax with Broncho-pleural fistula. Patient was being given oxygen, antibiotics and antibiotics. He continued to have chest pain and needed an escalated dose of analgesics. The fluid in the intercostal bag continued to drain at a rate of 150 ml per day with bubbling indicative of Broncho-pleural fistula. After a decision among the faculties of pulmonary medicine it was decided to instill autologous blood for the first time in our Dept. after explaining to the attendant.
Till 13th June 2021 in spite of 10 litres oxygen inhalation, the patient didn’t have clinical recovery of pneumothorax closure. So on 14th June 2021, 40 ml blood was taken from left cubital vein and instilled in 2 aliquots of 20 ml each and instilled into the right pleural cavity at 10 min interval to observe any aggravation of pain or any side effect. The patient was asked to sleep on the left decubitus position for over 3 hours and we were on vigil to manage side effects if any. Post procedure, chest X-Ray revealed no iatrogenic complication. The patient was observed for one week and chest X-Ray on 23rd June 2021 showed full lung expansion.
Pneumothorax following COVID may occur due to multiple factors like – high positive pressure ventilation, violent cough or rupture of cyst in the lung. Autologous blood patch is a modality of treatment of pleurodesis agent that was on back burner over one decade due to emergence of new pleurodesis agents such as talc, doxycycline and betadine. However, these drugs can cause pain, ARDS in selected populations. There is scanty data on use of biological agents like autologous blood, C. diphtheria, etc. In view of persistent pain and hypoxia, a poor general condition which precludes surgical intervention, this autologous blood patch was given and success was achieved in post COVID lung with persistent pneumothorax with Broncho pleural fistula.
Autologous blood patch is an alternate technique used in patients with alveolar-pleural fistula with or without complete lung expansion. In this procedure, the patient’s own blood (usually 100 ml) is directed to pleural space via chest tube. The proposed mechanism of action is likely due direct sealing of air leak as well as induction of pleural inflammation and eventual pleurodesis.
This is one of the safer and painless techniques, first of its kind in KIMS in the Pulmonary Medicine Department.